1811038862 NPI number — DR. SARAH JB ORTH PSY.D.

Table of content: DR. SARAH JB ORTH PSY.D. (NPI 1811038862)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811038862 NPI number — DR. SARAH JB ORTH PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ORTH
Provider First Name:
SARAH
Provider Middle Name:
JB
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PSY.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811038862
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 N VIRGINIA ST
Provider Second Line Business Mailing Address:
SUITE 245
Provider Business Mailing Address City Name:
CRYSTAL LAKE
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60014-3426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
708-288-2735
Provider Business Mailing Address Fax Number:
708-590-3351

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
101 N VIRGINIA ST
Provider Second Line Business Practice Location Address:
SUITE 245
Provider Business Practice Location Address City Name:
CRYSTAL LAKE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60014-3426
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
708-288-2735
Provider Business Practice Location Address Fax Number:
708-590-3351
Provider Enumeration Date:
02/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  071-006358 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 01632854 . This is a "BCBSIL PPO PROVIDER NUMBE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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